Multi-layered teams of doctors, nurses and therapists, 35 people in all, united to deliver and keep alive three boys and three girls born 10 weeks early and ranging in weight from 1 pound, 10 ounces to 2 pounds, 15 ounces.

"It's an amazing sight, the way skilled specialists come together to successfully manage multiple births," said Dr. William Gibbons, Texas Children's director of reproductive endocrinology and infertility. "At the same time, these are not successful outcomes; these are not outcomes we want."

Texas Children's reported Thursday that five of the Perkins children are "doing as well as would be expected" given their premature birth. The sixth, the tiniest, faces "greater challenges," the hospital said.

But the reality is that the children of high-end multiple births - quadruplets, quintuplets, sextuplets, septuplets and octuplets - often don't survive. If they do, they often have developmental disabilities, such as cerebral palsy or blindness, that require intensive, long-term care.

That reality was brought home this month in a journal review of children conceived through two common infertility treatment methods. The review in Fertility and Sterility found babies made with the help of either method were 37 percent more likely to have a birth defect than those conceived the old-fashioned way.

Since the birth of the first "test tube baby" in 1978, estimates put the number of children born with the help of reproductive technology at more than 3 million.

Though still rare, multiple births increased as those technologies become increasingly popular over the next three decades. The birthrate of twins doubled. Just in 2006, 67 births of quintuplets or higher were reported.

Under pressure, the industry began to regulate itself. But critics say the steps haven't resulted in much change.

"It's a little less wild than the Wild, Wild West of the 1980s," said Art Caplan, a bioethicist at the University of Pennsylvania. "But it's still pretty much a free market out there, more a free market than regulated medical practice."

In-vitro progress

The greatest strides have come with in-vitro fertilization, the treatment in which eggs and sperm are united in a petri dish, then returned to the womb.

After the American Society for Reproductive Medicine issued guidelines in 1998 urging specialists to implant only one embryo in most cases, the number of multiple births from the procedure declined significantly. When news surfaced that the doctor involved in the birth of octuplets in California implanted eight embryos, the society kicked him out, then successfully pushed for his license to be revoked.

But IVF is expensive and usually not covered by insurance. Cycles typically range from $12,000 to $25,000, shutting out many couples.

Instead, many of those couples turn to intrauterine insemination - the method the Perkinses used - cheaper and more likely to be covered by insurance, but less effective and essentially unregulated.

Another process

The technique, thought to be used twice as frequently as IVF, stimulates a woman's ovaries with hormones and implants sperm directly into the uterus. Doctors have little control of how many eggs are produced and, as a result, intrauterine insemination is the major cause of high-end multiple births.

The reproductive medicine society is beginning to look at how to regulate the method - a registry to establish better data, for starters - but officials acknowledge that it won't be easy, given intrauterine insemination's low cost ($2,000 to $3,000) and simpler nature.

An estimated 1,000 to 2,000 times a year, women pregnant with multiple fetuses will undergo "selective reduction," the aborting of some to increase the likelihood the others will survive and thrive.

Oppose 'reduction'

But Dr. Samantha Pfeif-fer, chair of the society's practice committee, says many couples initially agree to this option but ultimately can't go through with it "once they see those hearts and legs and arms on the ultrasounds."

Lauren Perkins says she agonized before opting not to selectively reduce.

"It was the hardest decision we've ever had to make and I don't wish it on anyone," wrote Perkins on the family baby website. "I was torn as to what was best for our family. I went back and forth every day and cried a lot."